-Formats for taking a health history: 1. Direct: Nurse asks for info. via direct interview w/informant (Superior, but not always practical bc of time constraint) 2. Indirect: Informant supplies info. by completing type of questionnaire. -Or combo. of both. -ID Info.
-Info. may be available fr. other recorded sources. -May ask about info. more in depth. -Informant: person who furnishes the info (parent, child, etc.) -CC (Chief Complaint) -Reason for visit -Ask open ended questions -Present illness: narrative of CC fr. earliest onset, thru progression, to present. 4 major components: 1. Details of onset 2. Complete interval hx 3. Present status 4. reason for weeking help NOW. -Pain=most characteristic symptom. Assess type, location, severity, duration, influencing factors. -History -Info. r/t all previous aspects of child’s health status, concentrates on several areas that are usually passedover in hx of an adult: -Birth hx: All data concerning mom’s health during pregnancy, L&D, infant’s condition right after birth, concurrent crises during pregnancy, prenatal attitudes towards fetus. -Open ended questionsàex: “Tell me about your child’s birth” -Feeding hx: Nutritional assessment -Immunizations: Most reliable source is a record of them. -Growth. weight at 6 mos., 1, 2, & 5 yrs. old. Length at 1 yr. & 4 yrs. Dentition (Number of teeth, s/s during teeth). -Development: Age of holding up head steadily, age of sitting alone w/o support, age of walking w/o assistance, age of saying 1st words w/meaning, present grade in school, scholastic grades, interactions w/other people. -Previous illnesses, injuries, operations: Ask specific questions about common illnesses as well as serious health problems. -Allergies -Current meds -Habits: Important to exploreàSleep patterns, use of chemicals (usually children or adolescents) -Sexual history: Important w/adolescentàmay need STD or pregnancy testing. Ask open-ended questions: “Tell me about your social life” -Family Medical Hx: Potential existence for hereditary or familial diseasesàusually just 1st degree relativesàage, marital status, state of health, cause of death, evidence of heart dz, htn, cancer, DM, obesity, congenital anomalies, allergies, asthma, seizures, TB, sickle cell, mental retardation, mental disorders, syphilis, rheumatic fever. -Geographic Location: birthplace, travel to different areas in/out of countryàpossible exposure toendemic dz’s. Close family members’ hx of travel, ie: military service, business trips. Childrenàeasily susceptible to parasitic infestation & vector borne dz’s. -Family Structure: Factor in emotional & physical health. Refers to composition of family: who lives in home and the social, cultural, religious and economic factors. -Psychosocial Hx: Observe how children handle themselves in confidence, in dealing w/others, answering questions, coping w/new situations. Observe parent-child relationship for messages sent about coping skills, self worth, body image. -Review of Systems: Specific review of each body system following similar order of physical exam.
-CAPILLARY REFILL -To tests for peripheral circulation -Press skin lightly on central site like forehead or peripheral site like top of hand or bottom of foot to produce slight blanching. -Amount of time it takes to return to original color=cap refill time. -Cap refill should be < 2 seconds -Prolonged = poor systemic perfusion or cool ambient temperature
1. Direct: Nurse asks for info. via direct interview w/informant (Superior, but not always practical bc of time constraint)
2. Indirect: Informant supplies info. by completing type of questionnaire.
-Or combo. of both.
-ID Info.
-Info. may be available fr. other recorded sources.
-May ask about info. more in depth.
-Informant: person who furnishes the info (parent, child, etc.)
-CC (Chief Complaint)
-Reason for visit
-Ask open ended questions
-Present illness: narrative of CC fr. earliest onset, thru progression, to present. 4 major components:
1. Details of onset
2. Complete interval hx
3. Present status
4. reason for weeking help NOW.
-Pain=most characteristic symptom. Assess type, location, severity, duration, influencing factors.
-History
-Info. r/t all previous aspects of child’s health status, concentrates on several areas that are usually passed over in hx of an adult:
-Birth hx: All data concerning mom’s health during pregnancy, L&D, infant’s condition right
after birth, concurrent crises during pregnancy, prenatal attitudes towards fetus. -Open ended questionsàex: “Tell me about your child’s birth”
-Feeding hx: Nutritional assessment
-Immunizations: Most reliable source is a record of them.
-Growth. weight at 6 mos., 1, 2, & 5 yrs. old. Length at 1 yr. & 4 yrs.
Dentition (Number of teeth, s/s during teeth).
-Development: Age of holding up head steadily, age of sitting alone w/o support, age of walking
w/o assistance, age of saying 1st words w/meaning, present grade in school, scholastic
grades, interactions w/other people.
-Previous illnesses, injuries, operations: Ask specific questions about common illnesses as well as serious health problems.
-Allergies
-Current meds
-Habits: Important to exploreàSleep patterns, use of chemicals (usually children or adolescents)
-Sexual history: Important w/adolescentàmay need STD or pregnancy testing. Ask open-ended questions: “Tell me about your social life”
-Family Medical Hx: Potential existence for hereditary or familial diseasesàusually just 1st degree relativesàage, marital status, state of health, cause of death, evidence of heart dz, htn, cancer, DM, obesity, congenital anomalies, allergies, asthma, seizures, TB, sickle cell, mental retardation, mental disorders, syphilis, rheumatic fever.
-Geographic Location: birthplace, travel to different areas in/out of countryàpossible exposure to endemic dz’s. Close family members’ hx of travel, ie: military service, business trips. Childrenàeasily susceptible to parasitic infestation & vector borne dz’s.
-Family Structure: Factor in emotional & physical health. Refers to composition of family: who lives in home and the social, cultural, religious and economic factors.
-Psychosocial Hx: Observe how children handle themselves in confidence, in dealing w/others, answering questions, coping w/new situations. Observe parent-child relationship for messages sent about coping skills, self worth, body image.
-Review of Systems: Specific review of each body system following similar order of physical exam.
-CAPILLARY REFILL
-To tests for peripheral circulation
-Press skin lightly on central site like forehead or peripheral site like top of hand or bottom of foot to produce slight blanching.
-Amount of time it takes to return to original color=cap refill time.
-Cap refill should be < 2 seconds
-Prolonged = poor systemic perfusion or cool ambient temperature